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1°1-ra5a zrAD. <br /> State of Oregon Department of Environmental Quality <br /> Annual Operation and Maintenance <br /> DEQ Report Form <br /> General Information (Complete ALL information) <br /> Nathan & Jennifer Dejong <br /> Property Owner: Phone; <br /> Site Address: 4734 71st. Ave. SE <br /> Parcel#: <br /> Salem <br /> City: County Marion <br /> Permit it Start up date if 1st year in use: <br /> System Model#: DF50 27596 <br /> System Serial#: <br /> Report Year: 2025 11/3/2025 <br /> Date of Service Performed: <br /> Email Address: <br /> Onsite wastewater treatment system status: (Do not prefill and photocopy checkboxes) <br /> tY�es No <br /> ry IJ Was maintenance performed as required by septic system rules and the manufacturer? <br /> ® ❑ Is the system operating in accordance with the agent-approved design specifications? <br /> gi ❑ Is the system currently under a service contract with a certified maintenance provider? <br /> ❑ © Is the system tailing? <br /> ❑ ® Discharge of sewage to the ground surface? <br /> ❑ ® Discharge of sewage to drain tiles or surface waters? <br /> ❑ ® Sewage backup into plumbing fixtures? <br /> If you answered-Yes"on the last four questions, was a repair permit obtained? If not, explain: <br /> I certify that this report is complete and accurate to the best of my knowledge. I understand that falsification of this <br /> report is grounds for revocation of my certification and/or civil penalties. <br /> *Maintenance Provider Name(please print): Austin Arts <br /> "Certification#: RM250 "Certification Expiration: 03/30/2027 <br /> ('This line only can be filled out and /) <br /> Original Signature: �.r-�i�.�� Date: kit/iC <br /> Note: Maintenance providers must maintain accurate records of their maintenance contracts,customers, <br /> performance data, and timelines for renewing the contracts. These records must be available for inspection upon <br /> request by the agency per OAR 340-071-0130(24). <br /> DFO Annual oneraaoon and Alamodance Hpport For, Iicv.ii'2022 <br />